As a member of the Rappahannock Area YMCA, Inc. I acknowledge receiving a copy of the membership privileges and responsibilities in the Welcome Packet. I understand it is my responsibility to read and adhere to those guidelines.

Definition of Family - “Family” includes the primary adult, significant other, and tax dependents as defined by the Internal Revenue Ser- vice. The YMCA reserves the right to ask for the most recent 1040 form or other documents, as well as the right to make exceptions as deemed necessary, which may incur an additional monthly fee per person added to the family pass.
I understand I will be required to verify full time student status or residence for any child over 18

I hereby grant the YMCA:
To take photos and/or videos of myself/and or my family and use them for publicity if they so desire.

In order to provide for convenient monthly payments to the Rappahannock Area YMCA, Inc., (the association), the member authorizes electronic funds (EFT) from specified checking/savings account or charge card in the amount of and on or after the date specified. The Association is authorized to change the payment date or amount from time to time by giving the member thirty (30) days written notice. If membership dues are increased , the member’s electronic funds transfer or charge can also be increased. Electronic Funds Transfer is subject to the rules of the Community Bank of the Chesapeake and the member’s agrees to bound thereby.
Member may cancel this authorization with thirty (30) days written notice before their next scheduled bank draft.
In no event shall a revocation of authority be effective with respect to entries to the bank honors electronic transfer by charging the specified amount or when the charge is made to the specified charge card, the funds transfer or charge shall constitute the receipt of payment. Should any electronic transfer or charge not be honored then it is understood that payment is to be made by the member in the amount of said payment along with a NSF draft fee or declined credit card charge. This agreement also allows the Association to initiate a reversing entry to a member’s account in the event that an error occurs.
- All outstanding balances on Membership Account must be made prior to Membership Cancellation.
- Membership dues paid are Non Refundable.

Membership changing from Student to Adult (19 years old) and from Adult to Senior Adult (62 years old) will automatically renew to the appropriate monthly rates during the first draft at which the primary member has reached the aforementioned age. Members with family memberships will need to notify Member Services when their memberships are due to convert to the senior family membership.

I have read the authorization statement for EFT, Charge Card payment or Fixed Term and authorize the payment as stated. I have read and understand the terms and “Definition of Family”

In consideration of my being allowed access to and usage of, the four Branches of the Rappahannock Area YMCA (the “facility”) and related equipment, machinery and amenities of the facility, and intending to be legally bound, I hereby agree: to follow all policies, rules and regulations of the facility, recognizing that violation thereof will, at the sole discretion of the officials of the facility, constitute grounds for immediate expulsion from the facility and revocation of the privileges afforded to me to access and to utilize the facility, and to waive, release, hold harmless, covenant not-to-sue, and forever discharge any and all rights, actions and claims that I or my heirs, executors, or assigns may have against the Rappahannock Area YMCA, Inc., as well as its respective officers, directors, trustees, agents, employees, volunteers, representatives, successors, assigns and affiliates for death, injury, loss and any and all damages that may be sustained and/or suffered in connection with being allowed to access and utilize the facility. I also agree to indemnify the Rappahannock Area YMCA for any defense, cost, or expense arising from my access and utilization of the facility. I am physically fit, legally competent and freely access and utilize the facility at my own risk.

I accept all provisions of membership set forth above and, understanding the Mission of the YMCA, hereby apply for membership. I understand that information given for my YMCA membership is the property of the YMCA and is kept confidential.